Applies to Employer and ACA Marketplace plans.
Covered (preferred drug)Qualification pathways
You can qualify through any one of these.
MASH/NASH with fibrosis — Wegovy as requested agent
All of:
- Diagnosis of noncirrhotic NASH or MASH confirmed by medical records
- Stage F2 or F3 fibrosis confirmed by liver biopsy within past 2 years, VCTE, ELF score, or MRE prior to therapy
- Alcohol consumption: female <20g/day OR male <30g/day (medical records required)
- Patient is currently on and will continue a weight management regimen (low-calorie diet, increased physical activity, behavioral modifications)
- Patient being monitored and/or treated for comorbid conditions (e.g., CVD, diabetes, dyslipidemia, hypertension)
- Patient age is within FDA labeling for the requested indication OR there is support for use at patient's age
- No decompensated cirrhosis, moderate-to-severe hepatic impairment (Child-Pugh B or C), or other liver disease
- Prescriber is a specialist in area of diagnosis (e.g., hepatologist, gastroenterologist) or has consulted with one
- No FDA labeled contraindications to Wegovy
- Requested quantity does not exceed program quantity limit OR meets criteria for quantity exception
FDA labeled indication other than MASH (alternative pathway)
All of:
- Patient has another FDA labeled indication for Wegovy
- Patient age is within FDA labeling for the requested indication OR there is support for use at patient's age
- No decompensated cirrhosis, moderate-to-severe hepatic impairment (Child-Pugh B or C), or other liver disease
- Prescriber is a specialist in area of diagnosis or has consulted with one
- No FDA labeled contraindications to Wegovy
- Requested quantity does not exceed program quantity limit OR meets criteria for quantity exception
Documentation to bring
- Medical records confirming diagnosis of noncirrhotic NASH or MASH
- Medical records confirming stage F2 or F3 fibrosis via liver biopsy within past 2 years, VCTE, ELF score, or MRE
- Medical records documenting alcohol consumption level (female <20g/day or male <30g/day)
- Documentation of current weight management regimen (low-calorie diet, increased physical activity, behavioral modifications)
- Documentation that patient is being monitored/treated for comorbid conditions
- Documentation that prescriber is a specialist or has consulted a specialist (e.g., hepatologist, gastroenterologist)
- Documentation of absence of decompensated cirrhosis, Child-Pugh B or C hepatic impairment, and other liver diseases
Approval and renewal
- Initial approval: 12 months
- Renewal: every 12 months
- Renewal: Patient must have clinical benefit with the requested agent. MASH/NASH diagnosis must be confirmed with ongoing medical records. Alcohol consumption limits re-verified (female <20g/day, male <30g/day). Weight management regimen (low-calorie diet, increased physical activity, behavioral modifications) must be ongoing. Fibrosis staging confirmation NOT re-required at renewal.
Not covered when
- Decompensated cirrhosis
- Moderate to severe hepatic impairment (Child-Pugh Class B or C)
- Any other liver disease (e.g., Wilson's Disease, hepatocellular carcinoma, hepatitis)
- Any FDA labeled contraindications to Wegovy
Policy note: Wegovy is listed as the preferred agent for MASH; Rezdiffra requires step therapy through Wegovy or documented inability to trial Wegovy before it is approved. The policy references FDA accelerated approval for MASH indication contingent on confirmatory trial. The 'other FDA labeled indication' pathway (Criterion I.B) allows approval without the MASH-specific criteria if the patient qualifies for another labeled use of Wegovy. For the MASH pathway, VCTE, ELF, and MRE do not have an explicit lookback period stated in the policy (only biopsy has a 2-year lookback).
Policy effective June 1, 2026 · verified June 2, 2026 · source: Policy 213 · View policy document (PDF)